A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client?

Obtain satisfaction with appearance.

Achieve steady weight loss.

Institute an exercise plan.

Regulate food portions.

Answer and Explanation

The Correct Answer is D

Choice A reason: While obtaining satisfaction with appearance is an important long-term goal, it is not the first step in treatment. Addressing the behavior itself is crucial before tackling self-image issues.

Choice B reason: Achieving steady weight loss is a goal that will likely result from regulating food portions and other treatment interventions. It is not the initial focus when establishing treatment goals.

Choice C reason: Instituting an exercise plan is part of a comprehensive treatment plan but is secondary to establishing control over eating behaviors.

Choice D reason: Regulating food portions is essential for reducing the frequency and volume of binge eating episodes, which is the immediate concern in binge eating disorder management.

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Correct Answer is D

Explanation

Choice A reason: While assessing breath sounds is part of a comprehensive evaluation, it is not the most critical intervention for a TIA, which primarily affects neurological function.

Choice B reason: Palpating the suprapubic region for urinary retention is important but not the priority intervention for a client with TIA, as it does not directly relate to the risk of stroke.

Choice C reason: Reviewing the client's daily medications is necessary for overall care but is not the most immediate concern upon admission for a TIA.

Choice D reason: Initiating neurological monitoring every 2 hours is essential for a client with TIA to promptly identify any changes or progression in neurological status, which could indicate a stroke. This is the most important intervention to include in the plan of care for a client admitted with TIA. Neurological monitoring allows for immediate intervention if the client's condition worsens, potentially preventing further ischemic damage.

A. Review the medical record for the date of insertion. B. Apply ice first, then a warm compress to the IV site. C. Document that the medication was not administered. D. Discontinue the painful IV after a new IV is inserted.

Correct Answer is D

Explanation

Choice A reason: Reviewing the medical record for the date of insertion is important but does not address the immediate concern of pain or potential complications at the IV site.

Choice B reason: Applying ice and then a warm compress may be used for phlebitis or infiltration, but if the client is experiencing pain, the priority is to address the potential for complications.

Choice C reason: Documentation is a necessary step, but it should not be the first action taken when a client reports pain at the IV site.

Choice D reason: If the IV site is painful, it may be indicative of infiltration, phlebitis, or another complication. The nurse should discontinue the painful IV and insert a new one at a different site to prevent further discomfort and potential harm to the client.

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A nurse is caring for a client with binge eating disorder. Which goal should the nurse establish first with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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